[Quality of life and symptoms before and after surgical treatment of rectovaginal fistula]. / Évaluation de la qualité de vie et des symptômes avant et après prise en charge chirurgicale des fistules rectovaginales.

INTRODUCTION: Rectovaginal fistula requires a complex management because it has an important psychological impact associated with impaired quality of life of patients. Thus, the aim of our study was to evaluate the improvement of the quality of life of patients after surgical management. METHODS: This is a retrospective study. We included patients operated between 2009 and 2014 for the treatment of a rectovaginal fistula, whose data were available and who agreed to answer a questionnaire. We evaluated the satisfaction of short-term and long-term patients on the answer to the basic PFDI-20 and PFIQ-7 questionnaires. We then evaluated whether there was an improvement in symptoms and quality of life after surgery. RESULTS: Nine patients were included but only 4 patients completed the PFDI-20 and PFIQ-7 questionnaires. Fistula was secondary to either surgical intervention (44%, n=4) or complicated perineal tear (44%, n=4) or unknown cause (11%, n=1). After surgery, we found the short term a significant decrease in stool incontinence, as there was no stool incontinence (0/5) in the postoperative period, while preoperatively 55% (5/9) (P=0.03). Postoperatively, 33% (3/9) of the patients had genital discomfort and 44% (4/9) had gas incontinence compared to 0% preoperatively (P=0.2 and P=0.6). There appears to be an improvement in pelvic static disorders after surgical management. However, we found a slight improvement in nauseous leucorrhoea in the immediate postoperative period, as the prevalence decreased from 33% (3/9) preoperatively to 22% (2/9) postoperatively (P>0.9). In the long term, we observed an improvement in the sensation of perineal heaviness and gas incontinence because only 25% (1/4) of the 75% (3/4) preoperative patients still showed slight discomfort (P=0.5). The quality of life and the emotional state of the patients were no altered postoperatively. Indeed, preoperatively, 50% (2/4) of the patients reported anxiety compared to 0% (0/4) postoperatively (P=0.4). Similarly, 75% (3/4) complained of a decrease in their quality of life (social, sports, etc.) preoperatively compared with 0% (0/4) postoperatively (P>0.9). CONCLUSION: A simple surgical management of rectovaginal fistulas would allow a significant decrease in stool incontinence and improved quality of life and their emotional state, which confirms the beneficial effect of this therapeutic strategy. LEVEL OF EVIDENCE: 4.

Epidemiology and outcome of cervical cancer in national institute of Morocco.

BACKGROUND: On behalf of the medical staff of the National Institute of Oncology of Rabat, we conducted a retrospective study to report epidemiology and 5-year outcomes of cervical carcinoma in Moroccan women. METHODS: We reviewed all women diagnosed with invasive cervical carcinoma in our institute between January 2006 and December 2006. Outcomes and prognoses are analyzed in patients who received at least one treatment. RESULTS: The analysis included 646 women. Median age was 50 years (23-85 years). Bleeding was the most frequent symptom (95 %). The most predominant histology was squamous cell carcinoma (94 %). The majority of patients were diagnosed at locally advanced stages (88 %). Among patients who received treatment (n = 550), the management was based on concurrent chemoradiotherapy in 69.7 % of cases. The median duration of follow-up was 60 months (range 2-78 months). Overall survival, progression free survival, and locoregional recurrence free survival were 63.2, 60.7 and 79.1 % respectively. Significant poor prognostic factors in univariate analysis included stage, tumor size, lymph node involvement, anemia and absence of response to radiotherapy. The prognostic significance of response to radiotherapy and stage were retained in multivariate analysis. CONCLUSION: Cervical cancer in our Institute is diagnosed at locally advanced stages. Two third of patients were treated by concurrent chemoradiotherapy. Outcome of Moroccan patients are comparable to that of western countries. Significant prognostic factors were stage, tumor size, lymph node involvement, anemia, and response to radiotherapy. The way to reduce the global burden of cervical cancer in our country continues to be the development of vaccination and screening programs.

Correlation of leukorrhea and Trichomonas vaginalis infection.

Trichomonas vaginalis is a common sexually transmitted infection (STI) causing vaginitis. Microscopy has poor sensitivity but is used for diagnosis of trichomoniasis in resource-poor settings. We aimed to provide a more reliable diagnosis of trichomoniasis by investigating an association with leukorrhea. Women presenting for evaluation of vaginal discharge, STI exposure, or preventative gynecologic examination were evaluated for Trichomonas infection. Vaginal pH was determined and microscopy was performed by the provider, who recorded the number of polymorphonuclear leukocytes (PMNLs) per epithelial cell and the presence of clue cells, yeast, and/or motile trichomonads. Leukorrhea was defined as greater than one PMNL per epithelial cell. Culture and a nucleic acid amplification test (NAAT) were used to detect T. vaginalis. Patients were evaluated for Chlamydia trachomatis and Neisseria gonorrhoeae using NAATs and bacterial vaginosis using Gram stains. Two hundred ninety-four women were enrolled, and 16% were found to have Trichomonas (46/294). Trichomonas infection was more common in parous non-Hispanic, black women, who reported low rates of contraceptive use (33% versus 17%; P = 0.02) and a STI history (85% versus 55%; P = 0.002). These women were more likely to report vaginal discharge (76% versus 59%; P = 0.02) and have an elevated vaginal pH (87% versus 48%; P < 0.001) and gonorrhea infection (15% versus 4%; P = 0.002). Leukorrhea was associated with a 4-fold-increased risk of Trichomonas infection. Leukorrhea on microscopy was associated with Trichomonas vaginitis. Patients with leukorrhea should be evaluated with more-sensitive tests for T. vaginalis, preferably NAATs, if microscopy is negative.

Purulent vaginal and cervical discharge in the diagnosis of pelvic inflammatory disease.

In this structured review, we evaluated purulent vaginal and cervical discharge as diagnostic tests for pelvic inflammatory disease (PID). Using a pretest probability of PID (diagnosed clinically) of 50%, we used the odds-likelihood formulation of Bayes' theorem to calculate post-test probabilities of PID (proven by laparoscopy or endometrial biopsy). If abnormal discharge was present, the post-test probabilities of PID ranged from 50% to 73%, with a mean value of 57%. If abnormal discharge was absent, the post-test probabilities ranged from 24% to 52%, with a mean value of 39%. Therefore, the presence or absence of excess white blood cells in vaginal or cervical discharge was not particularly helpful in confirming or excluding PID in patients in whom the diagnosis was suspected from the clinical examination.

Prognostic factors and clinicopathologic characteristics of invasive adenocarcinoma of the uterine cervix.

OBJECTIVE: The purpose of this study was to evaluate the outcome of patients with cervical adenocarcinoma and to determine the characteristics and the prognostic factors of this entity. STUDY DESIGN: This retrospective study was done in the Department of Surgical Oncology of the Salah Azaiz Institute of Tunis with 79 cases of invasive adenocarcinoma of the uterine cervix that were collected from 1990 to 1999. Survival was analyzed according to the Kaplan-Meier method. Univariate analysis of prognostic factors was performed with the test of log rank. Cox regression model was used in multivariate analysis of prognostic factors. RESULTS: Mean age was 50 years, and metrorrhagia was mostly revealing in 73% of the cases. Early stages (I, IIa, IIb with 1/3 proximal parametrial invasion) and "pure" type adenocarcinoma were found in 78% and 87% of the cases, respectively. Treatment consisted of a radiosurgical combination in 52 cases; exclusive radiotherapy was practiced with 17 patients. The 5 year-overall and disease-free survival percentages were, respectively, 68% and 72.4%. Poor prognostic factors were age >50 years, tumor size >4 cm, advanced stage, tumor grade, and lymph nodes and lymph-vascular space involvement. With the use of multivariate analysis, only stage and lymph node metastases remained significant prognostic factors. CONCLUSION: This report shows survival and prognostic factors that are similar to those found in previous studies, but unlike the Western countries, our results demonstrate a high rate of early stages and no increase in frequency of cervical adenocarcinoma.

Efficacy and safety of a contraceptive vaginal ring (NuvaRing) compared with a combined oral contraceptive: a 1-year randomized trial.

This open-label, randomized, Phase III study compared the efficacy and tolerability of and compliance with NuvaRing, a combined contraceptive vaginal ring releasing 15 microg of ethinylestradiol (EE) and 120 microg of etonogestrel daily, with those of and with a combined oral contraceptive (COC) containing 150 microg of levonorgestrel (LNG) and 30 microg of EE. Subjects received NuvaRing or a COC for 13 cycles (3 weeks of ring/pill treatment followed by a 1-week ring-/pill-free period). A total of 1030 subjects (NuvaRing, n=512; COC, n=518) was randomized and started treatment (intent-to-treat [ITT] population). The percentage of women in the ITT population who completed the trial was 70.9% for the NuvaRing group and 71.2% for the COC group. Five in-treatment pregnancies occurred in each group, giving Pearl indices of 1.23 for NuvaRing and 1.19 for the COC. Compliance with both treatments was excellent and both were well tolerated. In conclusion, NuvaRing has comparable efficacy and tolerability with a COC containing 150 microg of LNG and 30 microg of EE and does not require daily dosing.

Contraception in hypertensive women using a vaginal ring delivering estradiol and levonorgestrel.

Contraception with a vaginal ring (CVR) that delivers estradiol and levonorgestrel was used during a mean of 15.6 menstrual cycles in 12 hypertensive women. Blood pressure (BP) was measured 5 times on each visit during 2 pretreatment control cycles; during the 1st, 2nd, 4th, 6th, and from the 9th to 12th cycles of CVR use; and again after a 1-month recovery period. No significant change in BP occurred during CVR use in any of the subjects. Plasma renin substrate and antithrombin III activity did not vary significantly, which suggests the utility of administering natural estradiol via the vagina, thus avoiding the first pass effect that occurs with oral contraceptives. Significant decreases in plasma sex hormone-binding globulin, cholesterol, high density lipoprotein cholesterol, phospholipids, and triglycerides occurred, indicating an androgenic effect of levonorgestrel. We conclude that the CVR is a method of contraception that does not elevate BP in hypertensive women.

PIP: Contraception with a vaginal ring (CVR) that delivers estradiol and levonorgestrel was used during a mean of 15.6 menstrual cycles in 12 hypertensive women. Blood pressure (BP) was measured 5 times on each visit during 2 pretreatment control cycles; during the 1st, 2nd, 4th, 6th, and from cycles 9-12 of CVR use; and again after a 1-month recovery period. No significant change in BP occurred during CVR use in any of the subjects. Plasma renin substrate and antithrombin III activity did not vary significantly, which suggests the utility of administering natural estradiol via the vagina, thus avoiding the 1st pass effect that occurs with oral contraceptives. Significant decreases in plasma sex hormone-binding globulin, cholesterol, high density lipoprotein cholesterol, phospholipids, and triglycerides occurred, indicating an androgenic effect of levonorgestrel. The authors conclude that the CVR is a method of contraception which does not elevate BP in hypertensive women.

Chylous metrorrhea.

Chylous is an extremely unusual cause of leukorrhea. The diagnosis is established by verification of the chylous nature of the discharge, documentation of its uterine origin, and lymphangiographic demonstration of dilated pelvic lymphatics with uterine reflux. Surgical excision of the incompetent lymphatic channels is the treatment of choice.

Symptomatic intrauterine retention of fetal bones.

Four patients with symptomatic intrauterine retention of fetal bones are discussed. Presenting complaints included infertility, irregular vaginal bleeding, vaginitis, and spontaneous passage of fetal bones. Two patients had uterine anomalies; 1 patient had a retained twin pregnancy. Pelvic ultrasound and x-ray films of the pelvic cavity are helpful in making a diagnosis. Hysteroscopy is invaluable both in confirming the diagnosis and in achieving successful removal of fetal bone.

Ectopic ureter: a rare cause of purulent vaginal discharge.

We report two cases in which urologic anomalies presented with vaginal discharge and fever in young women, aged 9 and 18 years. Both patients were ultimately diagnosed as having duplicated collecting systems with ectopic upper-pole ureters opening into the introitus. Although congenital urologic anomalies are a rare cause of vaginal discharge in young women, they should be included in the differential diagnosis of patients presenting with these symptoms.

Treatment of cervical ectropion by cryosurgery: effect on cervical mucus characteristics.

Eighteen women with cervical ectropion and 12 women with ectropion and vaginal discharge were treated by cryosurgery. Evaluation of the cervical mucus characteristics by cervical score and in vitro penetration test was performed before treatment and 2 months later. In the group with ectropion only (group A) the total cervical score was 5.7 +/- 0.4 and 11.9 +/- 0.06 (P less than 0.001) (mean +/- standard error) before treatment and 2 months later, respectively. In the group with ectropion and vaginal discharge (group B) the total cervical score before and after cryosurgery was 3.8 +/- 0.4 and 11.8 +/- 0.1 (P less than 0.001), respectively. In vitro penetration tests in group A before and after treatment were 0.72 +/- 0.1 and 2.9 +/- 0.08 (P less than 0.001), respectively. In group B, in vitro penetration tests before and after cryosurgery were 0.25 +/- 0.1 and 2.8 +/- 0.1 (P less than 0.001), respectively. It appears that cryosurgery improves the cervical mucus characteristics. It is recommended that infertile patients with hostile cervical mucus and ectropion will be treated by cryosurgery.

Comparison between OM-GA Cu and Copper-T IUCDs.

OM-GA Cu and Copper-T IUCDs were compared in a randomized prospective clinical trial in two-hundred women and followed up for two years. Dysmenorrhea and dyspareunia were more frequent with the Copper-T. Menometrorrhagiae, vaginal discharge and pelvic inflammatory disease were similar with both IUCDs. Two-year pregnancy rate for the OM-GA Cu was 5.4% and 3.2% for the Copper-T. Expulsion rate was 11.9% for the OM-GA Cu and 5.3% for the Copper-T. The OM-GA Cu users had less dysmenorrhea and dyspareunia but a higher expulsion rate compared to the Copper-T.

A multicenter study of levonorgestrel-estradiol contraceptive vaginal rings. I-Use effectiveness. An international comparative trial.

PIP: Contraceptive vaginal rings (CVRs), with approximate daily release rates of 250-290 mcg of levonorgestrel and 150-180 mcg of estradiol and manufactured in a shell design, were studied for effectiveness and acceptability in multicentered trials involving 1103 ring users in Brazil, Chile, Dominican Republic, Sweden, U.S., Denmark/Finland, and Nigeria. A comparison group of 533 women used the oral contraceptive Nordette. Both 1st and all segment 1 year gross pregnancy rates among CVR users were less than 3/100, rates similar to Nordette users. Continuation at 1 year was 50/100 users of the ring (all segments) and 38/100 among Nordette users, more of whom were lost to follow-up. Gross 1 year rates of termination for medical reasons ranged from 25-29/100. Ring users were more likely to terminate for vaginal problems and pill users for headache, nausea, and associated reasons. These trials indicate that CVRs of this design are as effective and have continuation rates equal to and possibly superior to Nordette under the same study conditions.^ieng

Persistent vaginal discharge in a sexually active adolescent female.

With the high prevalence of unprotected sexual activity among adolescents, health-care providers are frequently called upon to evaluate patients with abnormal vaginal discharges. Usually, thorough pelvic and laboratory examinations will identify offending organisms which can be promptly eradicated with the judicious use of antibiotics. Occasionally, however, an abnormal discharge may persist despite these interventions. Health-care providers need to be aware of the fact that anal intercourse may be a common practice among sexually active teenagers. Penile-vaginal contact after anal intercourse may cause vaginal discharge due to contamination. Health-care providers should make it a routine part of their history-taking of adolescent patients to inquire about anal intercourse. Not only might it reveal useful clinical information, but it may indicate the need for additional health education and counseling.

Unusual causes of vaginitis (excluding trichomonas, bacterial vaginosis, and Candida albicans).

When patients consult a gynecologist with repeated symptoms that cannot be diagnosed and do not respond to usual therapies, unusual causes of vaginitis should be considered. These include hormonal considerations, such as increased leukorrhea, and possibly amebiasis. Careful travel history should be taken in such patients. The less common sexually transmitted diseases that may cause unusual symptoms and sores should also be considered. Noninfectious allergic contact will continue to be a problem owing to the continued marketing of vaginal products for a variety of cosmetic indications. The simple of dictum of "seek and you will find" will also exclude retained tampons and other foreign objects. Psychosocial support should be given to patients when all likely causes have been excluded or all our scientific diagnostic approaches have been exhausted.

Candidosis of the genital tract in non-pregnant women.

Of 300 non-pregnant women seen in an STD clinic, 94 (31.3%) harboured C. albicans or C. glabrata in the genital tract; 84 of these women (89.4%) had at least one moderate or marked symptom or clinical sign. Of the 94 women with Candida, 50 had another genital infection; 38% of these 50 women had at least one moderate or marked symptom or clinical sign, compared with 75% of the 44 women with no other infection. This difference is significant. Of the 146 women taking oral contraceptives, 51 (34.9%) had Candida, compared with 43 (27.9%) of the 154 women who were not. The incidence of trichomoniasis, anaerobic vaginitis and non-specific genital infection was lower among women with Candida than among the others.

PIP: This prospective study was aimed at determining the prevalence of specific signs and symptoms in nonpregnant women harboring Candida albicans in the lower genital tract. Of 300 women randomly selected from a sexually transmitted diseases clinic, 93 (31%) harbored C albicans and 1 carried C glabrata in the lower genital tract. Perineal isolations were recorded in 58 (62%) of the 94 women with Candida. 50 of the women had another genital infection. 84 (89%) of the 94 women with Candida had at least 1 moderate or marked symptom or clinical sign, predominantly vaginal discharge. Of the 300 women studied, 146 were using oral contraceptives (OCs); 51 (35%) of OC users had Candida compared with 43 (28%) of nonusers--a nonsignificant difference. Finally, the incidence of trichomoniasis, anaerobic vaginitis, and other nonspecific genital infection was lower among women with Candida than among the others.

New developments in the etiology and pathogenesis of bacterial vaginosis.

Bacterial vaginosis is unlike the "classic" sexually transmitted diseases. Unlike cervical infection with Chlamydia or salpingitis caused by N. gonorrhoeae, no single etiologic agent has been identified, and the organisms which are associated with infection have all been found as members of endogenous vaginal flora, with the possible exception of Mobiluncus species. If, as we suspect, BV is due to interactions among various organisms found in the vagina during vaginal health, we must determine what changes in the microbial or chemical ecology determine the development of BV. If, for instance, BV is simply due to an inversion in the concentrations of various organisms such that the anaerobes which are usually present in low numbers become predominant and the lactobacilli which usually predominate become few in number, we must determine which causes what. That is, does some organism or environmental change allow the anaerobes to overgrow and thereby inhibit the lactobacilli, or does some change inhibit the lactobacilli, thereby, allowing the other flora to overgrow? Answers to questions such as these await further research.

Vaginal douching. Who and why?

Despite the long history of vaginal douching and its estimated practice by more than 67 million U.S. women, little is known about who those women are or why they douche. We addressed these questions by studying 618 women from urban gynecology practices. Fifty-nine percent had douched at some time, with the most frequent reason given as hygiene. The solutions used were evenly divided between commercial and home preparations. Three characteristics stood out among the women who douched: lower socioeconomic status, greater risk of sexually transmitted diseases and symptoms suggestive of vaginal infection. These characteristics were most common among women who douched frequently. The results suggest that douching has a strong cultural component but also raise the possibility that douching may be done in response to a perceived infection, possibly one transmitted through sexual contact.

PIP: Although an estimated 67 million US women douche, little is known about who practices vaginal douching and for what purposes. These questions were addressed in a study of 618 women 18-50 years of age who sought gynecological care at 4 sites (a hospital-based academic practice, 2 private practices, and a women's center) between July 1986-June 1987. 366 (59%) of these women had douched at some time. Of these women, 85% douched less than once a month, 12% douched at least once a month but less often than once a week, and 3% douched at least once a week. Women who douched were more likely to be black, less educated, younger, and of lower socioeconomic status and less likely to use spermicides or barrier contraceptives than their counterparts who did not report this practice. A comparison of the symptoms and reproductive histories of the subgroups in this study revealed two main trends. First, symptoms indicative of vaginal infection were significantly more common among women who douched; discharge was 3 times as common and vaginal irritation and abdominal or pelvic pain were twice as frequent than in non-douchers. Second, women who douched were more likely to have characteristics reflecting a high risk of sexually transmitted diseases (STDs); a history of prior gonorrhea, trichomoniasis, pelvic inflammatory disease, or other STD and the existence of 2 or more sexual partners in the previous month were reported significantly more frequently than in nondouchers. All of these characteristics increased in prevalence with increases in the frequency of douching. Two thirds of women stated they douched for reasons of hygiene. Although douching does not appear to be adopted to prevent or treat infection, symptoms of infection may affect the frequency of this practice.

Delayed reaction to the Dacron buttress used in urethropexy.

Eleven patients developed a delayed reaction to the Dacron buttress used in Stamey urethropexy. The reaction was characterized by pain, dyspareunia, vaginal discharge and/or bleeding, induration of the abdominal incision, vaginal granulation tissue and draining abdominal or vaginal sinus tracts. This complication occurred in 5% of the 163 patients we treated with the Stamey procedure for stress urinary incontinence. Treatment consisted of removal of the nylon suture and Dacron buttress. None of the 11 patients developed recurrent incontinence. The subjective cure rate for stress urinary incontinence was 92% using the Stamey procedure.

Giant cervical polyp. A case report.

BACKGROUND: Very large cervical polyps are rarely reported. CASE: A giant cervical polyp, 17 x 10 x 5 cm, protruded through the vaginal introitus in a 27-year-old, sexually inactive woman. CONCLUSION: Although carcinomatous change occurs in 1.7% of cervical polyps, malignant degeneration did not occur in the six reported cases. Thus, biopsy of these tumors before excision may not be necessary.